(must be completed if patient under 16, if same as above leave blank)

Please answer these questions fully or discuss them with your dentist. Information about your medical history is for your dentists use only.

Past/Current Medical Conditons

I agree that the above information is true and accurate record. I understand that payment on the day of treatment is required. Any expenses, costs or disbursements incurred by the My Dental Care @ West End in recovering any outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible party above. I further acknowledge that failure to attend any appointment without notice may also result in a deposit requirement prior to future appointments being scheduled. I have read and agree with the privacy statement on the back of this document.